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2023 Star Ratings: What to Know and What to Do Now

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Plan Preview 2 is underway and has kicked off a flurry of energy and enthusiasm in pursuit of quality excellence in Medicare Advantage. Plans know their Star Rating, causing either extreme joy or panic, and measure-level national performance trends are now known. While we await the full public release of the ratings, we know a great deal already.

National quality performance decreased pervasively.

For the first time since the inception of Star Ratings, actual quality performance decreased dramatically and pervasively this year. The national average rate decreased for 65% of this year’s measures and, despite cutpoints being calculated in a way that assigns ratings which account for these drops, the national average rating decreased for 85% of measures. This is particularly noteworthy since there was only one measure added in 2021, so the performance struggle reflects real struggles in long-known, long-established measurement areas.

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Actual performance decreased so pervasively that the average Part C and D Improvement measure ratings decreased to 2.6 stars and 2.7 stars, respectively. This equates to more than one full star drop on the Part C measure, and a full 1.5 star drop on the Part D measure. When actual performance declines are combined with the 2021 increase of Patients’ Experience and Complaints measures to 4x, many plans’ ratings dropped. It will be tempting to blame a decrease in ratings on the end of the extraordinary COVID relief added to the Extreme and Uncontrollable Circumstances (EUC) policy for the 2022 ratings. We encourage plans whose ratings dropped to acknowledge the gift CMS gave plans last year through COVID EUC policy relief and use the National Averages in Attachment C to the Technical Notes and three to five years’ of data in leadership messaging this week to help justify resource allocations needed for Stars improvement efforts. Though most measure rates did not return to pre-COVID performance levels in 2021, we expect significant recovery on long-standing measures in 2022 and 2023 which will impact cutpoints in the opposite direction imminently.

Almost 50% of cutpoints eased.

Centers for Medicare & Medicaid Services (CMS) does not arbitrarily set cutpoints, but rather collective performance on each measure determines cutpoints. The 2023 Star Ratings are the first ever where the cutpoint methodology provides plans ratings relief to account for the decreasing measure performance.

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Contrary to the decreased performance and cutpoints on HEDIS and CAHPS measures, Part D cutpoints continued to rise despite no change in the national average performance. We also see a significant easing of 2- and 3-star cutpoints, with less easing among high performers who drove more success on 4- and 5-star cutpoints.

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The Technical Notes set the stage for more sweeping changes to Star Ratings.

CMS added verbiage to page one of the Technical Notes signaling more imminent change to come. The intentional alignment of Stars to the Meaningful Measures structure spotlights the many important clinical, behavioral, pharmacy and experiential areas for which reliable quality measures exist but have not yet been introduced to Star Ratings.

Technical Notes

CMS also warns of the imminent transition to digital quality measurement, which will apply to both clinical and survey measurements within the next few years and for which NCQA has openly supported using Star Ratings and quality bonus payments as incentive for plans to switch to digital measurement.

As the Department of Health and Human Services and other federal agencies prepare for the potential that more than 60% of Medicare beneficiaries will be enrolled in Medicare Advantage (MA) plans by 2032, and for partial Medicare Hospital Trust Fund insolvency (which covers Part A) by 2028, it will be both vital and inevitable to add more measures to chase the cost reduction component of the Triple Aim. A careful comparison of the measurement categories called out by CMS in this paragraph of the Technical Notes offers a reminder of the many critical areas for which there are few, or no, measures currently in the Star Ratings program.

This year’s Plan Preview 2 is a return to normal in Star Ratings. It is the first of many years of intense competition, significant program and performance changes, and CMS’ use of MA plans to change healthcare. Every day and week matters to make sure your plan gets or stays on a strong trajectory. Here are six things to do immediately before public ratings release:

Validate CMS’ math.

The remnants of EUC math on the 2023 ratings is complicated. Recheck your Improvement measure calculation to ensure that the right measures were excluded based on use of the EUC policy. Additionally, validate the application of the EUC policy to your Health Outcome Survey measure ratings this year. Recompute your overall ratings with/without Improvement measures, and make sure you have no math errors.

Don’t hyper-index on 2023 cutpoints.

Plan leaders love to believe that cutpoints are predictable, and that prior year cutpoints alone are a reliable predictor of the future. But cutpoints are nothing more than a reflection of historical relative performance. With the significant changes in healthcare and clinical care patterns in 2022, there is no reason to thinks that Measurement Year (MY) 2021 historical experiences are as useful as benchmarks for MY2022 expected performance without making adjustments to account for post-COVID return to reality. Compounding the expected return to more normal measure rates in MY2022 and MY2023, we are now two-thirds of the way through the first measurement period for which CMS will apply the Tukey Outlier deletion model to cutpoints. This will put upward pressure on MY2022 cutpoints to save CMS $4.1 billion in quality bonus payments by 2030. Integrate Tukey calculations into MY2022 reporting and goal setting to ensure that fourth quarter initiatives drive success.

Get serious about CAHPS quickly.

CAHPS and member experience have been the focus all year. Fourth quarter is when this matters most. Make sure to message all unpleasant 2023 changes to members through direct and meaningful interactions so no member is surprised when they seek care or visit their pharmacy in 2023. Message negative formulary changes, changes to cost-share or copays, and the removal or erosion of benefits. Phone calls and home visits are both hard and expensive to perform but there is no path to a 4+ Star Rating without strong CAHPS scores.

Align your fourth quarter press and Stars Roadmap with new knowledge and needs.

With many plans still working remotely, driving rapid, impactful change has been harder this year than many expected. Use your new Plan Preview 2 urgency to hyper-index on specific measures, priorities and 2023 needs that may have languished amidst the struggle of remote work. Resist the temptation to add governance, committees, meetings and processes that do not drive new work. Assign roles and accountability for results but leave as much workday time free as you can to help those who need to act quickly to think thoroughly through situations, to schedule the time they need to execute the work, and to execute.

Consider best practices realistically.

Many plans are still working too hard trying to keep up with other health plans. Replicating best practices of any specific competitor is no longer feasible for the new needs of Stars. This is the time to really know your plan’s mission, vision, and strategic plan and align Stars workplans with leadership.

Prepare leadership for the still-unknown 2023 Star program changes.

Executive attention to Star Ratings is never as intense or engaged as it is during Plan Preview 2. While leadership will ask this week for retrospective analysis underneath the 2023 Star Ratings, make sure to convey not only what you need for MY2022 but also the many things you may need for MY2023 and MY2024. It’s inevitable that CMS is going to add health equity to Stars imminently, numerous new measures can still be added for MY2023, and there’s only another 16 months before the challenging 3x-weight Health Outcomes Survey measures return to Stars. Executives need to understand, support and resource all of these things alongside this year’s fourth quarter push.

Tip: If any one of your contracts received an overall rating, a Part C summary rating, or a Part D summary rating under 3 stars, sound the alarm bell loudly and immediately to leadership. CMS will begin denying new contract applications and applications for service area expansions for any parent organization that has any contract with any overall or summary ratings for two or more years beginning in 2023. Any contract receiving a 2.5-star indicator in their 2023 ratings is already 66% of the way through their all-important second year. There is still time to salvage MY2022 performance to prevent the second year of the 2.5-star rating, but the math is extremely detailed and complicated to ensure the summary ratings are captured in the work. For parent organizations with multiple contracts, it’s often small and inconsequential contracts where new work is going to need to be performed to prevent the entire parent organization’s expansion plans from being placed at risk due to this provision. There is no time to wait if you own one of these contracts and have any desire to expand in plan year 2024!

We know how hard it is to succeed in Stars amidst an era of change, when decisions must be made with no safety net and when both the risks and stakes of decisions are high. If you need help to ensure your success in 2022, call us. Healthmine loves helping plans achieve and sustain strong ratings. Email Melissa Smith at melissa.smith@healthmine.com for more information.

Melissa is a well-known thought leader and healthcare strategist with proven success developing enterprise-wide solutions to improve Star Ratings, HEDIS scores, quality performance, health outcomes, and the member experience. As EVP of Healthmine’s advisory division, she helps clients evaluate market dynamics and opportunities, optimize distribution channels, and fulfill strategic planning needs.

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